Podcast Summary
Long acting injectables improve adherence and outcomes for chronic psychotic illnesses: Long acting injectables reduce relapse, hospitalization rates, and even extend lifespan for individuals with chronic psychotic illnesses by improving treatment adherence.
Long acting injectable antipsychotics can significantly improve treatment adherence and outcomes for individuals with chronic psychotic illnesses like schizophrenia. These medications, which are more commonly used in Europe than in the US, can reduce relapse and hospitalization rates, and even extend lifespan. Studies have shown that adherence to oral antipsychotics is often poor, and nonadherence is a leading cause of relapse. Long acting injectables, which require less frequent dosing, can help overcome this issue. For example, some formulations last for up to six months. A Swedish study of over 29,000 patients found that those taking long acting injectable antipsychotics had a 30% lower risk of all cause mortality over a seven-year period compared to those taking the same medication in oral form. This is a compelling argument for the use of long acting injectables in the treatment of chronic psychotic illnesses.
LAIs superior for adherence and reducing violence: LAIs lead to better patient outcomes through increased adherence and reduced violence, making them a valuable alternative to oral medications
Long-acting injectable antipsychotics (LAIs) are superior to oral medications in terms of adherence and reducing violence, as discussed in the conversation. The injectable medications, such as those using decanoates or microcrystals, are designed to remain in the muscle and they release the medication gradually over time. This makes them more effective and reduces the need for frequent dosing. The process of administering these injections is simpler than many psychiatrists might think, and they can learn how to do it with the help of a nurse. The trust between the patient and the psychiatrist also increases when the psychiatrist personally administers the injections. Overall, the use of LAIs can lead to better patient outcomes and improved compliance.
Long-acting injectables for antipsychotics: Consistent medication levels over extended periods: Long-acting injectables for antipsychotics provide consistent medication levels, reducing side effects from sharp peak plasma concentrations, but carry risks of rapid release and potential overdose.
Long-acting injectable forms of certain antipsychotic medications, such as aripiprazole and olanzapine, release the medication into the bloodstream slowly after being injected. These formulations, which include aripiprazole monohydrate, aripiprazole lauroxil, and olanzapine PAM08, are designed to provide consistent medication levels over extended periods. However, there are risks associated with these injectables. For instance, olanzapine PAM08 carries a small but significant risk of rapid release, leading to potential overdose and sedation. This risk is why patients are required to be monitored for three hours post-injection. In extreme cases, hospitalization may be necessary. Despite these risks, the long-acting injectables offer advantages, such as fewer side effects due to the absence of sharp peak plasma concentrations. Additionally, they are suitable for any situation where an oral antipsychotic would be appropriate. It's important to note that these injectables are not contraindicated but should be used with caution, especially when ensuring a patient responds to the medication before committing to a long-term treatment.
Switching from oral antipsychotics to long-acting injectables: Consider differences in dosing, administration, and cost when switching from oral antipsychotics to long-acting injectables. Older injectables may require loading doses, while newer ones have simpler dosing regimens but may not provide high enough levels for individuals requiring larger oral doses.
When switching from an oral antipsychotic medication to a long-acting intramuscular one, it's important to consider the differences in dosing and administration. For older antipsychotics like haloperidol decanoate and fluphenazine decanoate, loading doses are necessary to reach similar plasma concentrations as the oral doses. The process can take several weeks, and the oral medication can be stopped once the second loading dose is given. Newer long-acting injectables, like Invega Sustenna for risperidone, have simpler dosing regimens but may not provide high enough levels for individuals requiring larger oral doses. Cost is also a significant factor, with older injectables being significantly less expensive than newer ones. It's crucial to understand these differences to ensure effective treatment and minimize potential complications.
Understanding the unique administration and dosing of antipsychotic medications is crucial for effective use.: Each antipsychotic medication has distinct administration and dosing requirements. Some, like aripiprazole, may require a second dose a week later, while others, like olanzapine and risperidone, do not. Knowing these differences can lead to shorter hospital stays and improved patient care.
The administration and dosing of antipsychotic medications can vary significantly between different drugs and countries. For instance, with aripiprazole (manufactured by Aristada), an initial dose is given followed by a second dose a week later, eliminating the need for an oral crossover. In contrast, olanzapine and risperidone do not require an oral crossover. Understanding the unique kinetics of each drug is crucial for effective use. For example, Invega SUSTENNA can be given as early as day 3 after the first dose, allowing for shorter hospital stays. While some medications like haloperidol decanoate and flufenazine decanoate may cause local reactions, the newer antipsychotics generally do not. In the case of Abilify (aripiprazole), it is often chosen due to its mild side effect profile, marketing efforts, and effectiveness in treating negative and cognitive symptoms. However, it's important to note that each patient's response to medication can differ, and individual factors should be taken into account when selecting a treatment.
Addressing Metabolic Health Concerns with Antipsychotics: Ziprasidone offers weight gain relief but poor absorption and lower efficacy. Metformin can prevent weight gain, but GLP-1 agonists like liraglutide are promising for those already experiencing weight gain and glucose intolerance, despite potential risks.
Ziprasidone, while an option for patients concerned about weight gain during antipsychotic treatment, has limitations such as poor absorption without a large meal and lower efficacy compared to other antipsychotics. Metformin is commonly used to prevent metabolic syndrome and antipsyschotic-induced weight gain, but for those already experiencing weight gain and glucose intolerance, GLP-1 agonists like liraglutide are a promising alternative, offering significant weight loss and normalizing glucose tolerance in most cases. However, potential risks such as thyroid cancer and gastrointestinal side effects should be considered. Psychiatrists need to be more proactive in addressing metabolic health concerns related to antipsychotics, with weight gain and glucose intolerance being key triggers for intervention.
Considerations for using semaglutide for weight loss: Semaglutide can aid weight loss but comes with potential risks like gastrointestinal side effects, pancreatitis, and high costs. Start with lower doses and gradually increase.
While antipsychotic medications like semaglutide (Ozempic) can be effective for weight loss, they come with potential risks and considerations. These include gastrointestinal side effects that tend to lessen over time, the possibility of rare pancreatitis and theoretical link to pancreatic carcinoma, and higher risks for those with diabetes or a family history of endocrine neoplasia syndrome type 2. It's also important to note that these medications can be expensive, and insurance coverage may require a pre-existing diabetes diagnosis. To maximize benefits and minimize side effects, it's recommended to start with lower doses and increase gradually. There have been cases of excessive weight loss leading to a lack of drive for food or water. Additionally, semaglutide may help reduce alcohol cravings, although this is off-label use. Due to its recent popularity, there have been pharmacy shortages.
Long-acting injectable antipsychotics and their interactions: Ensure safe use of long-acting injectable antipsychotics during pregnancy. Risperidone, the parent compound of paliperidone, is more affected by 2d6 inhibitors, leading to potential side effects. Measuring plasma concentration and dose reduction can help manage akathisia, but avoid routine use of Benzodiazepines due to increased mortality risks.
Long-acting injectable antipsychotics have gained popularity in various communities, including Hollywood, due to their effectiveness in managing mental health conditions. However, it's crucial to ensure their safe use, especially during pregnancy. Regarding the interaction between a strong 2 d 6 inhibitor and risperidone versus paliperidone, risperidone, the parent compound of paliperidone, will be more affected by the inhibitor, leading to higher doses and potential side effects. For akathisia, a condition characterized by restlessness, measuring the plasma concentration of the drug is the first step, followed by dose reduction and, if necessary, mirtazapine or Klonopin. However, it's important to note that the routine use of Benzodiazepines, including Klonopin, should be avoided due to increased mortality risks in the schizophrenic population. Overall, staying informed about the latest research and best practices is essential for effective treatment and patient care.
Helping the seriously mentally ill population with long acting injectable antipsychotics: Long acting injectable antipsychotics can improve mental health outcomes for seriously mentally ill individuals by reducing hospitalizations, preventing relapse, and stabilizing their condition, but gaining consent and building trust is essential.
The seriously mentally ill population in the United States is vastly undertreated, and long acting injectable antipsychotics can be a valuable tool to help break the cycle of hospitalization, discharge, decompensation, and prevent relapse. These medications can make a significant difference in getting individuals out of psychosis and stabilizing their condition, reducing the risk of brain damage and relapse. However, the challenge lies not only in the availability and use of these medications but also in building trust and gaining consent from patients, especially those with low insight into their illness. On a larger scale, as a society, we need to commit to better supporting and caring for our seriously mentally ill population, providing adequate housing, treatment, and social services, as seen in models from countries like Italy and Austria. Unfortunately, a significant portion of the chronically homeless population suffers from severe psychotic illness, and addressing the complex issues that lead to homelessness, such as trauma and abuse, is crucial for improving mental health outcomes.
Addressing housing needs for complex mental health conditions: Providing stable housing is crucial for individuals with complex mental health conditions like schizophrenia and chronic trauma, as chronic stress of homelessness worsens mental health. The 'housing first' approach prioritizes housing before other services is effective.
Addressing the housing needs of individuals with complex mental health conditions, such as schizophrenia and chronic trauma, is crucial for their overall well-being. The chronic stress of homelessness can worsen mental health conditions, even with medication. The "housing first" approach, which prioritizes providing stable housing before other social services, has been effective in helping this population. The lack of a stable shelter can lead to worsening mental health due to the physical and emotional tolls of being homeless. It's important for future mental health professionals to understand this complex issue and work towards solutions. The housing crisis is not an easy problem to solve, but with dedication and collaboration, progress can be made. If you're listening from Europe and working in complex mental health systems, please reach out for potential collaboration. Let's continue the conversation on this important topic. I will send you the articles we discussed later today, and I encourage those interested to explore them further.